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Keywords
Bacterial aetiology, Children, Developing countries,
Hearing impairment, Otitis media
ABSTRACT
Aim: Evaluation of clinical characteristics, bacteriology and hearing in paediatric
Correspondence
A Taipale, Department of Otorhinolaryngology,
Helsinki University Central Hospital, Helsinki,
Finland.
Tel: +358 44 35 19 607 |
Fax: +358 47 17 5010 |
Email: anni.taipale@fimnet.fi
Received
29 November 2010; revised 14 January 2011;
accepted 21 January 2011.
DOI:10.1111/j.1651-2227.2011.02192.x
patients with and without chronic suppurative otitis media (CSOM) in Luanda, Angola.
audiometry and brainstem auditory-evoked potentials of 23 outpatients with CSOM and
23 controls in a paediatric hospital.
Results: Of the CSOM vs. control children, 35% vs. 26% had running water, 70%
vs. 70% electricity, 64% vs. 0% HIV (p < 0.0001) and 36% vs. 0% tuberculosis in history
(p = 0.002). Ten (43%) children had bilateral CSOM. The major ear-discharge pathogens
were Proteus spp. (44%) and Pseudomonas (22%). Hearing impairment of >25 dB was
present in 52% of CSOM-affected ears and bilateral hearing loss in 7 (30%) CSOM
children vs. zero control child (p = 0.009). Only one hearing-impaired childs family had
previously detected the handicap.
Conclusion: CSOM occurred in children with high co-morbidity. Persistent otorrhoea
was usually caused by Proteus spp. or Pseudomonas, and often suggestive of either HIV or
hearing impairment. In the developing countries, prompt diagnosis and treatment of CSOM
would enhance the childrens linguistic and academic development.
INTRODUCTION
Chronic suppurative otitis media (CSOM) is a chronic
infection within the middle-ear cleft and mastoid cell system, producing persistent otorrhoea through a perforated
tympanic membrane. In the developing countries, the condition often develops as acute otitis media, failing to resolve,
leads to tympanic perforation and purulent ear discharge.
In these countries, childhood CSOM, usually a localized
infection without systemic symptoms, may not be
considered a disease needing special attention. Therefore,
the incidence, characteristics and consequences of CSOM
for children in the developing countries are not well characterized.
Chronic otitis most heavily affects certain indigenous
populations, such as those living in Australia (1) and Western Pacific (2). Among these groups, as well as others, environmental factors predisposing to the disease include
crowding (36), malnutrition (2,5) and exposure to contaminated water (2). The main aerobic organisms involved
include Staphylococcus aureus, Pseudomonas and Gramnegative enteric rods (1,2,710). In the resource-poor developing countries, childhood CSOM is one of the leading
causes for acquired hearing loss, carrying potential adverse
effects on the childs linguistic development (11).
In the African countries, previous paediatric chronic
otitis data, mainly concerning school-age children, suggest that hearing loss occurs in the majority of cases.
Data from younger children are sparse (913). An earlier
report from Angola shows that chronic otitis affects a
substantial portion, up to 4.6%, of schoolchildren (10).
Our aim was to evaluate CSOM-associated morbidity,
middle-ear bacterial aetiology and the hearing status, in
comparison with disease-free controls, among children in
Luanda, Angola.
Key notes
Abbreviations
BAEP, brainstem auditory-evoked potentials; CSOM, chronic
suppurative otitis media; PTA, pure-tone audiometry; WFA,
weight-for-age.
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2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica 2011 100, pp. e84e88
Taipale et al.
Table 1 Background and characteristics of 23 children with chronic suppurative otitis media (CSOM) and 23 control children of Luanda
CSOM children (%)
Female
Median age in months (range)
Median size of household (range)
Total
Children
Running water at home
Electricity
Attendance at national vaccination programme
Median duration of breastfeeding, months (range)
Malaria, earlier
Tuberculosis currently or earlier
HIV positivity
Malnutrition
Acute pulmonary infection
Rhinorrhoea
Tonsils grade 2+
Cervical lymphadenopathy
Ear pain (currently or earlier)
Earlier episodes of otorrhoea
Subjective hearing impairment
Hearing impairment observed by guardian
Hearing impairment in family
11 (48)
51 (13138)
6 (311)
2 (17)
8 (35)
16 (70)
20 (87)
18 (124)
20 (87)
8 22 (36)
14 22 (64)
8 (35)
9 (39)
9 (39)
3 (13)
15 (65)
23 (100)
23 (100)
2 (9)
3 (13)
6 (26)
p value
11 (48)
54 (10150)
6 (311)
3 (17)
6 (26)
16 (70)
17 (74)
18 (337)
21 (91)
0
0
2 (9)
1 (4)
5 (22)
7 20 (35)
5 (22)
3 (14)
0
0 (0)
0
8 (35)
0.96
0.58
0.75
>0.99
0.26
0.11
>0.99
0.002**
<0.0001***
0.07
0.01*
0.34
0.16
0.007**
<0.0001***
<0.0001***
0.49
0.23
0.75
2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica 2011 100, pp. e84e88
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Taipale et al.
RESULTS
Characteristics of the children
Table 1 shows the background and clinical characteristics
of the two study groups. Compared to the control children,
the children with CSOM significantly more often presented
with tuberculosis (p = 0.002), HIV (p < 0.0001), acute pulmonary infections (bronchitis and pneumonia; p = 0.01),
cervical lymphadenopathy of >1 cm (p = 0.007) and earlier
episodes of ear pain (p < 0.0001) and otorrhoea
(p < 0.0001).
Characteristics of CSOM
Of the 23 children with CSOM, 10 (43%) had bilateral disease (18 ears right, 15 left). The median duration of otorrhoea was 12 months (range: 2 months7 years). Fourteen
(61%) children were receiving antibiotic treatment, an oral
combination of sulphonamide and trimethoprim (12), local
topical gentamycin (1) and intravenous ceftriaxone and
cloxacillin (1). Six (75%) of the eight CSOM children with
tuberculosis were HIV positive. Eleven (79%) of the 14
HIV-positive CSOM children were receiving antiretroviral
treatment. One CSOM child showed delayed speech resulting from neonatal meningitis. None manifested facial nerve
dysfunction or bacterial mastoiditis.
Bacteria and antibiotic susceptibility
The typical pathogens derived from the ear-discharge samples were Proteus (44%) and Pseudomonas (22%). All successful cultures yielded one bacterial isolate (Table 2).
Among the Gram-negative bacteria, resistance occurred
against amoxicillin in 64%, amoxicillinclavulanic acid in
60% and trimethoprim-sulpha in 71%. All tested strains were
susceptible to ceftriaxone, ceftazidime and ciprofloxacin.
Otoscopy and hearing
Table 3 shows the gender, age, otoscopy and hearing thresholds of each child with CSOM. The total occurrence of
hearing loss in the CSOM group was 17 33 (52%) in the discharging ears and 3 13 (23%) in the dry ears. Seven (30%)
CSOM vs. zero control children (p = 0.009) had bilateral
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DISCUSSION
This study suggests paediatric CSOM in Luanda occurs in
children with poor living conditions and high co-morbidity.
One-third of the patients lived in households without electricity and two-thirds without running water. One-third
appeared malnourished in terms of low WFA. Previous
studies have identified malnutrition (2,5) and exposure of
auditory canals to contaminated water (2) as risk factors for
CSOM. The proportion of malnourished children in this
study falls between the 27% among the CSOM children of
Solomon Islands (2) and 37% in Nigeria (5). In this study,
however, the control children shared the same characteristics, which may in fact be the general reality of children in
the developing countries.
The most striking feature of our studys CSOM children
was HIV positivity, found in over 60%. Even though paediatric HIV infection is known to associate with chronic otitis
(13,14), reports concerning the role of HIV among the risk
factors for CSOM in the developing countries were unavailable. Considering the recently published epidemiological
data from Angola (15), showing a markedly low HIV prevalence among the adult population (3.7%), our data suggest
HIV is real risk factor for CSOM in children of Luanda.
When encountered in health care units, children with
CSOM should always be tested for HIV positivity. Another
finding, the higher prevalence of respiratory tract infections
and tuberculosis among the CSOM children, may also
partly derive from the childrens HIV positivity,
compromising their general immunity. In our CSOM group,
female gender characterized the children with both HIV
and tuberculosis; otherwise, the disease profile in this
subgroup equalled rest of the CSOM children.
Each of our successful ear-discharge cultures yielded one
bacterial isolate, with a predominance of Proteus and Pseudomonas species. S. aureus was not detected. The majority
of the strains proved resistant against common oral antibiotics, but not resistant to third-generation cephalosporins
and ciprofloxacin. Previous CSOM reports from the developing countries described cases of varying and often
polymicrobial bacterial aetiology, mostly including Gramnegative rods and S. aureus (7,9,10,1618). In addition, previous studies from the developing countries have detected a
resistance pattern resembling ours (10,17). Given the natural resistance of gram-negative rods to the traditional oral
antibiotics, as well as the limited local availability of topical
2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica 2011 100, pp. e84e88
Taipale et al.
Table 3 Gender, age, hearing and otoscopy in 21 children with chronic suppurative otitis media in Luanda
Child
HIV tuberculosis
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
M, 95
M, 96
M, 80
F, 43
F, 138
M, 92
M, 49
F, 50
M, 94
M, 28
M, 51
F, 22
F, 24
M, 51
F, 20
F, 65
M, 61
F, 13
M, 14
M, 24
F, 37
F, 69
F, 127
))
++
+ unknown
))
))
)+
)+
)+
+)
))
)+
)+
++
Unknown +
))
++
)+
)+
))
))
++
++
++
Suppuration 48*
Suppuration 28*
Normal TM 24*
Suppuration 40
Suppuration 25*
Suppuration 45*
Suppuration 40
Suppuration 60
Suppuration 40
Middle-ear effusion 40
Suppuration 80
Suppuration 40
Suppuration 40
Suppuration 60
Suppuration 80
Suppuration 29*
Suppuration 40
Suppuration 40
Suppuration 40
Dry perforation 40
Suppuration 40
Dry perforation 31*
Retracted TM 30*
Suppuration 41*
Suppuration 24*
Suppuration 63*
Dry perforation 40
Dry perforation 28*
Suppuration 41*
Normal TM 40
CI 40
CI 40
Suppuration 60
Suppuration 80
Suppuration 40
Suppuration 40
Suppuration 60
Suppuration 80
Dry perforation 23*
Suppuration 40
CI 40
CI 40
Suppuration 40
Suppuration 40
Suppuration 41*
Suppuration 33*
Cerumen impaction.
the poor availability of ear surgery in the developing countries are hardly avoidable. Therefore, higher awareness of
CSOM symptoms and risks is essential. CSOM-related
hearing loss is also a problem in developing countries with
lack of hearing aids. Recognizing the childs hearing loss is,
however, important in order to find other supportive measures before school age. The HIV positivity in this studys
CSOM children further underlines the need for early diagnosis and treatment.
ACKNOWLEDGEMENTS
We thank all the children, guardians and the personnel of
the Hospital Pediatrico David Bernardino. Special thanks
go to Elizabete Anjos and Marlene Pardal who performed
most of the diagnostic laboratory tests in Luanda. This work
was financially supported by research grants from Vaino
and Laina Kivis foundation and Ear Research Foundation.
References
1. Couzos S, Lea T, Mueller R, Murray R, Culbong M. Effectiveness of ototopical antibiotics for chronic suppurative otitis
media in Aboriginal children: a community-based, multicentre,
double-blind randomised controlled trial. Med J Aust 2003;
179: 18590.
2. Eason RJ, Harding E, Nicholson R, Nicholson D, Pada J, Gathercole J. Chronic suppurative otitis media in the Solomon
Islands: a prospective, microbiological, audiometric and therapeutic survey. N Z Med J 1986; 99: 8125.
2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica 2011 100, pp. e84e88
e87
Taipale et al.
e88
12. Bastos I, Reimer A, Lundgren K. Chronic otitis media and hearing loss in urban schoolchildren in Angola a prevalence
study. J Audiol Med 1993; 2: 12940.
13. Chow JH, Stern JC, Kaul A, Pincus RL, Gromisch DS. Head
and neck manifestations of the acquired immunodeficiency
syndrome in children. Ear Nose Throat J. 1990;69:4169,
4223.
14. Karpakis J, Rabie H, Howard J, Janse van Rensburg A, Cotton
MF. Otorrhoea is a marker for symptomatic disease in
HIV-infected children. S Afr Med J 2007; 97: 12924.
15. Bartolo I, Rocha C, Bartolomeu J, Gama A, Marcelino R,
Fonseca M, et al. Highly divergent subtypes and new recombinant forms prevail in the HIV AIDS epidemic in Angola: new
insights into the origins of the AIDS pandemic. Infect Genet
Evol 2009; 9: 67282.
16. Hussain MA, Ali EM, Ahmed HS. Otitis media in Sudanese
children: presentation and bacteriology. East Afr Med J 1991;
68: 67985.
17. Nwabuisi C, Ologe FE. Pathogenic agents of chronic suppurative otitis media in Ilorin, Nigeria. East Afr Med J 2002; 79:
2025.
18. Hatcher J, Smith A, Mackenzie I, Thompson S, Bal I, Macharia
I, et al. A prevalence study of ear problems in school children
in Kiambu district, Kenya, May 1992. Int J Pediatr Otorhinolaryngol 1995; 33: 197205.
19. Olatoke F, Ologe FE, Nwawolo CC, Saka MJ. The prevalence
of hearing loss among schoolchildren with chronic suppurative
otitis media in Nigeria, and its effect on academic performance.
Ear Nose Throat J 2008; 87: E19.
20. Seely DR, Gloyd SS, Wright AD, Norton SJ. Hearing loss
prevalence and risk factors among Sierra Leonean children.
Arch Otolaryngol Head Neck Surg 1995; 121: 8538.
2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica 2011 100, pp. e84e88
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